F.E.A.S.T's Around The Dinner Table forum

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So, in searching for cause and cure for our daughter's ED we have pursued underlying issues such as adoption trauma, poor self-esteem, bullying and so on through traditional therapy and pharmaceuticals - mixed results with this approach. Now we are proceeding with a behavioral approach with much quicker results vis-a-vis daughter's physical health. What I wonder is, if we completely discard the search for underlying psychological issues are we treating only the symptoms? Will this leave the door open for ED down the line?
Tempest -18 yo daughter diagnosed with EDNOS since 15, FBT at home WR 12/13, relapse 10/14, Residential 2015 for 3 months, PHP several weeks. New dx bi-polar. Home now seeing good treatment team weekly, attending college. D still occasionally purging but weight stable.
Tempest -

I am a "fixer" by nature and therefore struggled with finding the cause of my d's ED as well.  Our PHP/IOP program explained it in a way that makes sense for me.  This was "our" d and I realize that it doesn't apply to all.  My d had an anxious personality from birth.  Even as a baby, she was different than her brothers on other side of her.  She was a poor sleeper and difficulty to comfort.  She didn't' especially like to be held.  As a child, she excelled in school, was outgoing and happy and showed perfectionistic tendencies. She also showed emotional lability.  Any behavioral issues I can see now were tired to anxiety.  My husband and I tried to minimize her distress by trying to keep her out of anxiety producing situations.  (This was not blame from our team, rather, I am the one that identified it. In fact, we have always had great relationships with our kids.  Difficulties in our relationship with our d didn't cause her ED, rather, the ED caused the fracture in our relationship.) The onset of ED for her was a "perfect storm" of her emotional makeup, genetic predisposition (lots of anxiety, depression, substance abuse on both sides of the family), issues with friends making poor decisions with boys and drinking and being selected for a pre-professional dance troupe where the time spent dancing doubled, anxiety about college acceptances, etc.  I was not on top of her nutritional needs and wasn't alarmed when she wanted to lose 5-10 pounds by eating healthy.  (Again, no blame, just a fact.  I had no reason to be alarmed, I didn't know any better.)  Of course, like so many, the eating healthy spiraled out of control and we were in ED land.

I DO think it is important to look at causes.  My d's genetic make up and personality type are not going to change. For us, skills based therapy has been incredibly helpful at managing her tendencies AFTER full and sustained nutritional rehabilitation and proper weight gain. DBT has been helpful for her to learn self care, to use her voice, etc. It has also been helpful for me as I struggled with some of the same anxiety issues (thus the genetic predisposition.) 

Two years ago my d had an ED, but we were a few months away from realizing it and starting treatment.  Last night at Christmas dinner we went around the table and said what we were looking forward to in 2014 and what the highlights of 2103 were.  Her 2013 started out slowly since she was in residential Feb and March.  She said that this time last year she didn't look forward to anything and today she looks forward to everything.  She has regular periods, is glowing with health, actually went above her weight range and has grown almost 2 inches at 18-19 and has returned to her old social self.  She is heading to her dream school out of state with a solid recovery plan with green, yellow, red light indicators and plans for what we all do in each situation. There IS so much hope from this dreadful disease. 

I have a son who is adopted from another country so I am especially sensitive to the adoption trauma issue.  He is only 12, so I know we will be dealing with some tough conversations as we head into adolescence.  Of course, he knows he is adopted and thus far in his life has thought it was a "cool" thing.  I have limited what I have told him to what he has asked.  I am hoping that what I have learned with my d will help me with this as well.  We have always hoped that if we just pour enough love into it, we can all help him through it!

Good luck to you and I hope this helps!
Enjoying my 23 year-old daughter's achievement of active recovery that was made possible by the resources and education I found on this forum.

Don't give up hope!
Gosh, can I just say how much I hate the words "underlying causes" (when uttered by a therapist)? IME, there is a HEAVY connotation of "things we can BLAME" to that phrase. Frankly, I think blamestorming the past is a completely useless activity. You can't do anything to CHANGE what has already happened, and to me, valuable time and resources are much more appropriately spent addressing what is happening now, and being better prepared for the future. Apportioning fault/cause/blame is *rarely* a productive part of that kind of process.

That said, I offer a reframe for how such an investigation might be useful, and indeed necessary. The reframe is that it is really useful to identify TRIGGERS; things that inspire, exacerbate, perpetuate ED behaviors. Because those situations, or circumstances represent potential "banana peels" to slip up on later in recovery. Identifying triggers is important to developing constructive alternative behaviors, and practicing their use, so that healthy recovery can be maintained.

Now, as part of understanding triggers, I am pretty sure it will often be useful to understand the cognitions that the person has along with those situations/circumstances (certainly that has been my experience). In practice, this does involve understanding the "meaning" a person attaches to triggers, and to their own behaviors, whether ED or not ED. The meaning each one of us attaches to our own experiences is hugely important, and it is silly to suggest otherwise.

But part of healthy development for humans, is developing the capacity to be "meta" about ourselves - the ability to understand that there can be a HUGE divide between how we are thinking and feeling on the inside, and what is going on in the world outside us. The ability to look at our internal processes as an outside observer, and do what is sometimes called "reality checking"; adjusting our interior thoughts and feelings when they have become wildly mismatched to the external world. ED (and indeed, many brain based conditions) do commonly impair people's abilities to do this well, and spontaneously. This is where I think therapies aimed at cognitions and emotions can be very helpful. But still, it is not necessarily examining "Origin of ED" events, so much as how ED (or any other maladaptive behavior pattern) is operating in the person's life at the present time.
I have quite a strong knee-jerk response to the phrase 'underlying issues' however I'm aware that my d's anxious temperament is part of the genetic makeup that is often seen in someone with an ed. Given no other choice (not much useful support on offer in our area), we concentrated on the restoration of physical health first. Just this led to massive improvements in her state. Since then however, we have also concentrated on enabling d to identify triggers, deal with stressful situations etc. etc.

Tbh, while I carry an internal burden of guilt about some things I've done over the years (you know, because I'm a mum & guilt comes way to naturally to us!), I decided at the beginning that seeking a 'cause' was irrelevant & would get in the way of helping her get better. Triggers, on the other hand, and healthy coping strategies do, I believe, need to be identified and addressed.
The future is not set; there is no fate but that which we make for ourselves.

"Not my daughter, you bitch." Mrs. Weasley
I don't think it is a bad thing to look for underlying causes.  For some, there may a single or series of events, history of anxiety and/or depression and for others there may be nothing to "pin" their issues on.  My un-professional opinion is, if there is an underlying cause that led to their current situation, teaching them to talk about it and come to terms about it will help them in the future.  I have seen girls who were sexually assaulted develop eating disorders. My thought is you can teach them to eat properly, but if you don't work with them, their experience will haunt them their entire lives and could lead to other issues in the future.
"What I wonder is, if we completely discard the search for underlying psychological issues are we treating only the symptoms? Will this leave the door open for ED down the line? "

Well, the underlying cause is genetic. And psychological stuff can make genetic stuff emerge. Think of diabetes. Some people are predisposed to it genetically. When will it emerge in the person's life? Well, that depends on what happens in their life.

What this means is that "trauma" doesn't cause ED in a person who isn't genetically predisposed to get one. Just like trauma doesn't cause schizophrenia or asthma.

Does it matter what tipped the scales over to ED starting? Whether it was puberty (rapid growth, difficult to keep up weight-wise), or stress, or what? Those things didn't cause the ED.
"Hope is a wonderful thing ... but hope by itself is not enough. Hope is the reason to take action, to make a plan and then to change the plan when it isn’t working - over and over and over again if necessary." Hannah Joseph (Let's Feast Friday Reflection, "Just Keep Going," Friday, March 3rd, 2015)
Here is the thing that strikes me; the route of learning to talk about issues has never been shown to affect the course of ED one way or the other. The clinical linking of the two is based on the idea that eating disorders develop BECAUSE a person cannot talk about trauma related issues. There is literally NO evidence that this is the case for the large majority of people with ED. I think continuing to behave as though this dynamic is somehow critical to ED development and maintenance for all sufferers, is extraordinarily problematic. 

The truth is far more nuanced than that.

  • Can a trauma act to trigger dramatic, and often maladaptive behaviors? Absolutely! 
  • Is this what happens 100% of the time a trauma happens? Absolutely NOT!
  • Does a maladaptive behavior pattern mean that there *must have been* a trauma? Absolutely NOT!
  • Is being able to talk about a trauma helpful to a lot - but NOT 100% - of people? Absolutely.
  • Is not talking about a problem the same as not being able to deal with that problem? Absolutely NOT! As a matter of fact, many people here have posted about how therapy in this direction has been counterproductive and a barrier to healing for their individual child.
  • Do you HAVE TO talk about a past trauma, if you never have, but are currently behaving in healthy and adaptive ways? Absolutely NOT!
This is what I mean about nuance - not only is there no "One Size Fits All", but some kinds of assumptions can be *harmful* in the cases where they don't apply.

When I discuss working through triggers, then to the extent that some past trauma is limiting current behavior, it is TOTALLY appropriate to unpack that past trauma. But the focus is NOT on unpacking the past, it is on moving forward in the NOW. And if the past is NOT affecting the now, I am dubious as to the value of spending time, money, raising anxiety, and diffusing clinical focus, on that past issue, rather than the material issues of nutritional and behavioral rehabilitation. 

Hopefulmama and Irish describe so well how ed invades it's victims. It is important to address issues that are or have been stressful or distressing for them. It won't do much good to work on psychological issues unless physical health is reasonably stable ,the brain is in a more healthy state and that point can be different for each individual. Learning actual skills to manage and recognize distortions , distress or emotions is very important. What hasn't been proven is that any of these things cause the ed. Think about how many kids with ed have no trauma or siblings that are well adjusted. To even label as cause is not helpful. I think the goal is to restore physical health as quickly as possible and to identify and treat any psychological issues along the way. Absolutely want to treat psychological issues but not as an underlying issue or cause of ed.

This issue came up during my D's Therapy visit today.   D asked me directly - what I think caused her ED. 

I gave her three answers:

1.  It doesn't matter.  It is what it is, and we need to focus on where we are:  With a continued focus on physical health, eating what she needs,  and coping strategies for the underlying anxiety. 

2.  There are so many variables and factors:  there is simply no ONE answer to that question.  It is likely to be a combination of genetics, environment, individual characteristics, family dynamics, life stresses, etc., etc., etc.  Focusing on the 'WHY' of it all is risky because it can lead to all kinds of stress, blame and GUILT.   We all spend some time in pity city... second-guessing ourselves and past behaviors - but at the end of the day, refer to #1.

3.  One thing I know for sure - IT IS NOT YOUR FAULT!!!!  (repeat, repeat, repeat)

17 yr old d dx RAN in June 2013.   W/R in Jan. 2014; as of May 2014- independently and doing well.  Read more at Paula-Ponders.com
I think we all at one point looked back and thought, " what the heck happened and how?"    Then for me after that thought I quickly went into 
let's just "fix" it!   How the heck do we get them to eat, main focus.  Nothing else mattered to me, just getting my d to eat, main focus!  With therapy, magic plate ect.....

Now that we have accomplished that goal,  I can evaluate her personality traits and through reading and learning I understand the how.  

The word "perfect storm" was mentioned,  I agree with that.   The other thing is trigger.  For us now we are working on the anxiety and OCD/perfectionist.     I was mentioning on a post of mine about d knowing herself what makes her anxious and working out a plan to curtail it.

Therapy is so important for my d.  She gets that support and the skills to help her learn how to deal with life.  

So,  genetic for sure.     No matter where d is in her recovery  I will never let my guard down, ever!  [smile]    
bicycle wrote:
I'm an newbie who learns something new every day! 

I believe that EDs are biological. Inherited brain wiring that "catches" the mind onto something. In my d's case: healthy (perfect) eating and exercise. Messages about obesity and fitness (at school) catch her mind's attention and she feels compelled to act (and act and act and act).  Soon her body and brain is malnourished because of underfueling.  The thoughts about being "lazy and fat" start somewhere in there, possible a symptom of starvation or perhaps before.  She had shown no signs of depression or body dissatisfaction or low self-esteem or delusional cognitions prior to the behaviors or the weight loss.
I think people try to explain psychological (mind=cognition/feelings) symptoms with psychology (there must be something that we can talk about and process and explain). Clearly there are biological brain illnesses with psychological symptoms (schizophrenia, OCD, bipolar) and I think ED is one of them.
I feel like our best bet is with ongoing physical recovery and behavioral interventions that *hopefully* will help rewire the brain. 

My d is weight restored 2+ months (maybe) and behaviors are not letting up yet.

This is how I think as well.  From the beginning, we were encouraged NOT to think about the "why" but rather to focus on getting D healthy again.  Now that she is healthy we are working on ways to keep her that way, which includes some CBT.

Like yours, my D was never particularly anxious.  Is not particularly OCD or a perfectionist.  She never seemed to care about body image.  She ate well, and often.  What happened?  I don't know, and I'm not sure I will ever know.  All I know is that we are headed in the right direction.

To me, it's sort of like Wilm's disease....kidney cancer that my friend's son has.  They spend ZERO time trying to figure out WHY he got cancer.  They are 100% focused on killing the beast.  And, that's what I'm doing too.
D, age 18, first diagnosed March 20, 2013, RAN, at age 13 Hospitalized 3 weeks for medical stability. FBT at home since.  UCSD Multi-family Intensive June 2015. We've arrived on the other side.  :-)  D at college and doing great!
I was molested and did not develop ED. My friend was raped. No ED. Another friend was in a horrible accident and had a tramatic brain injury. No ED. I have holocaust survivors in the family. No ED.

I really don't think that trauma does, in and of itself, cause ED. If ED happens, it is because the biological tendency was there, genetically. If there had been some other condition there and not ED, the trauma may have made it also emerge--whether depression or schizophrenia or hypertension or whatever. Trama makes underlying conditions appear, in my opinion, but can't make something happen that isn't in the genetic code. If it could, there would be lots more ED, because there is lots more trauma out there than ED.
"Hope is a wonderful thing ... but hope by itself is not enough. Hope is the reason to take action, to make a plan and then to change the plan when it isn’t working - over and over and over again if necessary." Hannah Joseph (Let's Feast Friday Reflection, "Just Keep Going," Friday, March 3rd, 2015)
I felt so much guilt when my D was DX -- and still do, a bit -- because I am perfectionistic and have always practiced disordered eating, which my D didn't mimic until... well, until she did, about 2 months before her DX. But I now believe that there were triggers that brought on my D's AN, and that the ED was there all along, lying in wait. Did she inherit it from me? Likely. My husband's sister has also displayed disordered eating, so maybe it was there, too, on both sides of the family. Did we cause it? I don't think so.

We've always characterized our D as the girl who falls off a dock and comes up with a fish. She is very laid back and never one to create or embrace drama. She never truly had to try very hard to be good at anything -- school, sports, art, dance… But when she was challenged -- her first year of high school's increased academic challenges, she was brought up from a JV lacrosse team to play varsity when she really wasn't ready, etc. -- her plan for healthy eating, increased workouts and sudden stress and feelings of not being good enough all came together for that proverbial perfect storm.

Just as we admired her ability to rise to any occasion, she assumed that this was always expected of her, even though we've encouraged her to not worry about grades, to enjoy the opportunities her school offers and to follow her passion. Deep waters run still -- that's the saying, isn't it? I think maybe my D's deep waters hid much more than a common teenage girl's insecurities, worries and fear -- it also held an ED, just waiting to rise to the surface.

Mom of 16-y-o D diagnosed w/ ED-NOS (RAN, compulsive exercise) in May 2013. Hospitalized for 2 wks then IOP at UCSD through July. Now in FBT w/ team of therapist, pediatrician and psychiatrist (for meds.). She is WR & considered to be in recovery, though we are diligently watching her and working on relapse prevention on a weekly basis with her T. We can finally see true recovery as a real possibility [biggrin]!

Wow. Such amazingly heartfelt  and inspirational comments from each of you... Thank you.  I have little to add to any of it, just that I too focus on the present, not the past or future .. my analogy is that if the tire is flat, you can get out of the car and agonize about how the road you had chosen made the tire go flat and how you shouldn't have taken that road... or you can agonize about what might have happened if you hadn't noticed the flat tire, and how you might have driven off a cliff if you hadn't found it out....Or, you can just work on changing the tire.
We are working on that tire.

dms I wish there was a like button for that analogy. I would add, once you have the tire changed and on the road again, then you have to look at the road ahead and make sure you don't get another flat.
D diagnosed restrictive AN June 2010 age 13.5. Weight restored July 2012. Relapse and now clawing our way back. Treatment: multiple hospitalisations and individual and family therapy.
My 12.5 yr old son's acute onset of severe restrictive anorexia had me searching for anything that would explain what had happened, why he had it and what would cure it. He was injured by a bully playing soccer and ended up with a nasty collar bone break that took him out of running for a spot on the elite level team. As a result he lost his appetite and was depressed and sad that we could not play. He told me later if he ate while he "wasn't doing anything" he would get fat.

Luckily we ended up with a medical doctor who has much experience of EDs. She explained it as a biological brain disorder that is genetic in nature. Her protocol was to re-feed my son and get him back to his pre-ED weight ASAP. Once that was done (not easy by any means) it has taken 31 months of feeding him 3 meals and 1 snack every day consistently for him to improve and his ED to be almost in complete remission.

Over those past 31 months (while he was weight restored and still growing and gaining) I saw rigid behavior, anxiety around meals, having to eat and shower, etc at the very same time every day (to the minute) OCD behavior, fear, anti-social behavior, an inability to concentrate on school work, a fear of bugs, picking his skin, having to style his hair for over an hour after every shower to be sure EVERY hair was in the right place, not being able to attend events of any kind, not being able to stay at someones house for more than 30 min, not being bale to have anyone visit our house,etc.

At this point I would say he has co-morbid anxiety - but his anxiety did not cause his ED. His genetic pre-disposition along with the weight loss due to his injury while he was in the middle of a huge growth spurt - did. 

Lots of food over time is medicine. Then you will see what co-morbids your D has.
I know this is easier said that done. 
I wish you could see my son today - he is the poster child for everything we don't think about when we think about anorexia.  

Son diagnosed @ 12.5 yrs old with Severe RAN 2/11. Co-morbids - anxiety, Active restriction for 3 months. He stopped eating completely 2x. He needed immediate, aggressive treatment from a provider who specialized in eating disorders, adolescents and males. We got that at Kartini Clinic. WR since 5/11. 2017 getting ready to graduate slipping lost 8lbs. Fighting our way back.
Thank you to all who have contributed to this discussion. So interesting and helpful reading all your stories and advice. I am trying to decide if we should continue with d's current T. Lately My D has expressed just being tired of all the ED talk and just wanting a normal teen life. She doesn't want to journal, do work books etc and in lots of ways she doesn't really seem to need this stuff. BUT, I am also afraid to let my guard down for a second.
Tempest -18 yo daughter diagnosed with EDNOS since 15, FBT at home WR 12/13, relapse 10/14, Residential 2015 for 3 months, PHP several weeks. New dx bi-polar. Home now seeing good treatment team weekly, attending college. D still occasionally purging but weight stable.
Tempest, I know the feeling of not wanting to let go of anything that might be helping, no matter how little it may be.  We kept our d in therapy for a long time just in case it was helping.

But I believe that the process of journaling and workbooking and focusing on ED can be detrimental sometimes.  It's tempting to believe that there could be some 'underlying issues' that could be resolved which would heal our children entirely and forever, but this is a brain disorder and it doesn't work like that.

I'm not a believer in 'underlying issues' that need resolving.  I know my own belief comes mainly from my own small sample of a well-adjusted girl who succumbed to AN after participating in a 30-hour famine for charity, but it's been reinforced by a lot of reading and five years here ATDT.  Healthy eating, pseudo-vegetarianism, exercise, dieting, failure to gain, etc all seem to be more implicated in the triggering of ED than trauma, real or subconscious.  Dredging for underlying issues is often a trauma all on its own IMHO.  And it sure doesn't cure ED.  It's been the go-to treatment for 40 years with a pretty abysmal track record.

You are on the right track with the behavioral approach.
Colleen in the great Pacific Northwest, USA

"What some call health, if purchased by perpetual anxiety about diet, isn't much better than tedious disease."
Alexander Pope, 1688-1744
My daughter (much younger--about to turn 9), also doesn't like to talk about ED or OCD (her AN is, we believe, an expression of OCD), except to get it behind her. She'll tell a problem she's having, we'll have a solution-oriented conversation, and on we go with LIFE.

Olivia says that talking about OCD too much makes it STRONGER. To make it go away, we have found the following to be helpful:
-->call it what it is. This is her first step in resolving the issue, whether food-related or related to something else
-->choose a strategy to manage it.
-->ask her if she wants me to check on her or to manage it herself.
-->on we go with LIFE
"Hope is a wonderful thing ... but hope by itself is not enough. Hope is the reason to take action, to make a plan and then to change the plan when it isn’t working - over and over and over again if necessary." Hannah Joseph (Let's Feast Friday Reflection, "Just Keep Going," Friday, March 3rd, 2015)
YP  No matter the age difference of our girls,  Your strategy works for my d also.   I think just having their weight restored makes it possible to handle the anxiety/OCD situations in such a manner.   I think it teaches our d's how to handle it and hopefully they will be able to do so more and more on their own.  Especially your little darling being so very young!    [smile]
There is absolutely no point in wasting time figuring out the " why". My D was ten and hit by the perfect storm situation as well. She never had any issues before Ed and she does not have any now in a solid recovery. For her, all of the OCD and anxiety was linked to the starvation. Not that she does not have anxiety now, but it does not seem to be above that of any of her 13 year old cohorts.

We are one of the rare families who do not have D in therapy. We had a few Skype sessions with an awesome therapist, but D really was saying what she thought she wanted to hear. She said she would rather talk to us....and she does. Talking to a therapist early on in refeeding etc was a total waste of time because D was just frankly too looney to get anything out of it and too young. She had no idea about why any of this happened or how. It just did. What was the point of talking about it? She needed to eat.

Maybe it will be useful in the future more to deal with stressors of getting older .. I don't know.... But I think part of recovery is NORMALCY in life and not talking about it all of the time. We went skiing today. We did not talk about it at all. Not for a second. In fact, it has probably been 2 weeks since we really full on talked about Ed.... Because there has not been a need to. When things relate to Ed or we see an opportunity to point out a situation where D used to deal with stress by restricting, we will talk about it.... But I really feel like the more we treat our d in recovery like she is "sick" then the slower the recovery is. Does that make sense? It is all about moderation. I am on welbutrin for depression/PTSD. I feel fantastic. I don't feel the need to see my therapist once a week like I was.... Now I go every few months just because I actually enjoy it and find it therapeutic in general.

Who the hell knows what causes eds. But it is definitely genetic and complicated...

But my daughter is the example of a non- complicated case. She restricted food, lost weight, and her brain completely malfunctioned... And food, weight gain, time, and lots of support from us has gotten her back into life. It wasn't easy... And we have years to go..., but there comes a time where Ed has to take a backseat to living again. Sometimes I think it is harder for me than my daughter now! FYI: I am writing this post as a mom who is 3.5 years into this now....my perspective.
Persistent, consistent vigilance!
We have a different situation because my D had AN before she experienced traumas. 

I agree with all that triggers can bring on some restriction in eating that will activate the ED for those biologically/genetically predisposed.

Not a cause, but a trigger that can cause restriction and weight loss, similar to a severe flu bug.

But I also see how when someone is acutely malnourished and their brain is very distorted - and then they experience serious traumas such as sexual assault the brain's wiring goes haywire and becomes even more distorted in significant ways.  In other words, they are already vulnerable with ED and add on the trauma and PTSD - it's like being in a warzone.

For any of our children, once they are WR and maintained long term, if there are other issues that need to be treated, whether it be PTSD from trauma, depression, anxiety, etc - it should be treated.

The reason being that without treatment of those comorbid conditions, they are vulnerable to relapse.

It takes strength, resilience and healthy coping skills to maintain remission long  term.

Not a black or white situation
WenWinning (formerly wenlow) - a Mom who has learned patience, determination, empathy, and inner strength to help her young adult daughter gain full remission after over a decade of illness and clinician set inaccurate weights
Absolutely not.
Persistent, consistent vigilance!